Eczemas due to mites and microorganisms

ROBERT JACKSON,* MD, FRCP[C]

Eczema is a specific clinical, products) may cause eczema (Table II) Under the microscope it may be more morphologic and microscopic reaction and to discuss what is known about difficult to find spongiosis or vesicula- pattern of the skin. It has many the mechanisms involved. tion because biopsy material allows one causes, including external and internal The term eczema, derived from the to examine only a small area at one chemicals and the action of various Greek word meaning to boil over or stage of the eruption. microorganisms - bacteria, fungi, erupt, describes a reaction in the skin Physicians trained in observation can yeasts, viruses and mites - and their and certain adjacent mucosae. It is construct a retrospective or prospective products. Peripheral vesicles with characterized by a series of gross le- picture so that they can say of a non- undermined borders are a feature of sions and histologic changes, as sum- vesicular eruption that it may have had all eczemas caused by fungi, yeasts marized in Table III. In some eczema- at one time, or it may develop, vesicles. and bacteria and are thus a useful tous eruptions one or more of these At times one cannot be certain. diagnostic finding. findings may be present at any one time, to the apparent exclusion of some Bacterial eczema L'eczema represente un sch6ma of the others. The fundamental lesion r6actionnel cutane cliniquement, of eczema is the vesicle (Fig. 1) or the Many patients with eczema have a morphologiquement et microscopi- spongiotic intercellular (Fig. 2) quement specifique. II y a plusieurs that produces the vesicle; unless this causes, y compris certains agents is present at some stage or in some area chimiques externes et internes et the eruption cannot be called eczema. l'action de divers microorganismes - bact6ries, fongus, levures, virus et acares - et de leurs sousproduits. Des v6sicules peripheriques aux contours profonds sont caracteristiques de tous les eczemas causes par les fongus, les levures et les bact6ries et constituent donc un element diagnostique utile.

Eczema is a common multiform reac- tion pattern in the skin caused by numerous and varied external and in- ternal stimuli (Table I). The purpose of this paper is to point out that dif- ferent types of microorganisms (or their

FIG. 1-Eczema on dorsum of hand: large number of small crusted vesicles.

,;4. * ,, *Dermatologist, Ottawa Civic Hospital; assistant professor of medicine (dermatology), University of Ottawa To be presented to the Ottawa Bacteriological FIG. 2.-Acute eczema: intercellular Club Feb. 10, 1977 edema of epidermis (spongiosis) and ex- Reprint requests to: Dr. R. Jackson, Ste. 508, tensive intraepidermal vesiculation (hema- 1081 Carling Ave., Ottawa, Ont. K1Y 4G2 toxylin-eosin; x250, reduced 50%). 156 CMA JOURNAL/JANUARY 22, 1977/VOL. 116 large number of bacteria growing in The favourable response to systemic eroded surface with a peripherally un- the eczematous area and in the normal antibacterial therapy reported (anecdot- dermined border (Fig. 6). This form adjacent skin, although the contents of ally) for some cases in the last two characteristically occurs in warm, the initial intact vesicle may be sterile. groups has implicated bacteria as being moist, body folds (for example, pen- Patch tests with autogenous broth cul- important in the cause of these types anal, genitocrural and inframammary tures or filtrates of Staphylococcus of eczema. This response, however, is areas and fingerwebs), especially in per- aureus (or with mixed bacterial cul- by no means always assured. sons with a deficient immune system. tures) show a strongly positive reaction, Often there are satellite vesiculopustules as manifested by areas of eczema be- Yeast eczema decreasing in number and size the neath the patch. Exacerbation of the farther they are from the primary inter- primary focus of eczema may be seen One form that of the skin triginous eruption. The earliest histo- after intracutaneous or subcutaneous due to Candida a)bicans can take is pathologic changes are localized spon- injection of an autogenous or mixed that of numerous small vesiculopustules giotic areas in the upper epidermis, vaccine. Some widespread eczemas, that coalesce to form a red, glistening, usually just below the stratum corneum, such as exudative "seborrheic" bacterial eczema, respond promptly to the ad- ministration of systemic antimicrobial agents. Storck1 reported that the eczemato- genic agent in bacteria is a protein that can act as an antigen without acquiring a protein linkage with the epidermis. Loewenthal,2 however, considered that it was also possible (and perhaps more likely) for the spread of eczema to be due to autosensitization of a patient to his skin, which is not uncommon when large numbers of bacteria are present; in this case the bacteria would join with some epidermal protein (the protigen of Epstein.) and cause the release of anti- genic epidermal protein into the blood stream, with subsequent development of eczema in distant areas. The long-claimed relation between foci of in such areas as the teeth, tonsils, sinuses, gallbladder and prostate has never been proven and is still based primarily on anecdotal re- ports. How do these findings relate to clin- FIG. 3-Pustular eczema with peripheral ical disease? The most obvious and undermining on amputated thumb with FIG. 4-Coccal eczema in lower portion clear-cut* bacterial eczemas are those underlying osteomyelitis. of retroanricular crease. that appear in areas of skin bathed continuously in pus discharging from, for example, the middle ear, an osteo- myelitis sinus or a leg ulcer. When the source of the pus is cleared up the eczema disappears (Fig. 3). All forms of true bacterial eczema are now rare, owing presumably to the widespread availability and use of antibacterial drugs to treat the underlying chronic purulent infection. Another type is the sharply margin- ated eczema with vesicles and pustules and a peripheral undermined border without any obvious underlying source of discharging pus. These were more common on the hands and fingers and had such names as repens and continua (Fig. 4). A third group consists of eczemas that present as discrete, coin-shaped erythematous plaques studded with small vesicles, usually on the legs, arms or forearms (nummular eczema) (Fig. 5). Clinical experience indicates that severe dryness (as produced by over- zealous washing with soap) is probably '1 H(.. 5-Nummular eczema on leg; bright FIG. 6.-Interdigital with un- an important causative factor. red lesions. dermined border. CMA JOURNAL/JANUARY 22, 1977/VOL. 116 157 which rapidly fill with polymorpho- 4. Failure to demonstrate fungi in nuclear leukocytes and serum.4 A filt- the secondary lesion. ered, sterile, phenol-treated extract of 5. Spontaneous clearing of the sec- disintegrated Candida cells (oidiomy- ondary eruption when the primary le- cm) reproduces typical cutaneous can- sion subsides, whether spontaneously or didiasis when applied to the skin as following treatment. a patch test. This reaction is mediated by an endotoxin-like substance released As with oidiomycin, skin testing with by organisms on the surface of the trichophytin (a filtered, sterile extract skin. Opinion varies as to whether the of phenol-treated fungus culture) is not spongiotic pustules are produced by the much help in diagnosing fungal infec- direct action of this substance or by tions. Apparently most of us are at an antigen-antibody reaction. Intra- some time exposed to the allergenic dermal injection of oidiomycin gives a components, so many persons will have positive tuberculin response in most pa- a positive test result even though they tients because most adults have been do not have an active fungal infection. exposed either to these fungi or to Patch testing with some trichophytin microorganisms with similar antigenic extracts may produce an eczematous or allergenic structures (hence, cross- reaction.7 The allergic constituents are reaction occurs). polysaccharides.8 Jones, Reinhardt and Rinaldi9 re- Fungal eczema cently did intradermal testing with a FIG. 8-Delled papules of molluscum purified trichophytin preparation, re- contagiosum. There are several types of superficial corded the number of patients showing fungal infections of the skin that are delayed sensitivity, and correlated this months or years. A perilesional halo of blistering and closely mimic the gross with the number of patients showing eczema about 5 to 10 cm in diameter morphologic and the histologic features clinical and cultural evidence of derma- develops in about 10% of patients," of nonparasitic eczemas5 (Fig. 7). tophytosis. Their data suggested that though not all the lesions in a patient One type is (eczema patients showing positive delayed sensi- will show this eczema. The eczema may marginatum), which has an arcuate tivity to trichophytin were immune and occur on adjacent touching body parts; vesicular border with undermining of those with a negative test result were for example, molluscum contagiosum the epidermis at the periphery. The susceptible to chronic fungal infections. with perilesional eczema on the inner central portion has a tendency to heal, Cruickshank, Trotter and Wood" aspect of the arm can produce eczema with slight scaling and browning and passively transferred trichophytin sensi- on the lateral chest wall where the af- sometimes lichenification. The genito- tivity in guinea pigs by means of pen- fected area of the arm touches it. Pre- crural, intergluteal and perianal areas toneal cells and, in so doing, estab- sumably, because not all the lesions are the sites of predilection. Epider- lished that the cell-mediated immune cause an eczema, the process is local; mophyton floccosum is one of the system is responsible for these delayed- also, because the eczema is transferable fungi causing this condition. type reactions. by contact, the eczematogenic sub- Blistering tinea also can produce ec- stance must be water-soluble. I know zematous changes in the interdigital Viral eczema of no reports of the identification or and intertriginous areas (for example, isolation of this antigenic material. tinea pedis due to Trichophyton menta- Molluscum contagiosum is a delled grophytes). The blistering causes the papular eruption occurring in clusters, outer epidermal layer to lift and peri- mainly in children (Fig. 8). It is Scabies mite eczema pheral undermining can easily be seen. caused by the molluscum contagio- Mellanby'2 showed that in nearly 900 The moisture in the area makes the sum virus, a poxvirus. The lesions are men with scabies the mean number of elevated epidermal layer appear white usually treated by curettage but if left parasites detected was 11.3, and that and macerated. alone will disappear spontaneously in half the patients had only 1 to 5 adult Another type is the eczematous erup- Sarcoptes scabiei (de Geer 1778 var. tion due to a specific sensitivity of the hominis Hering 1880) (Fig. 9). Clearly, skin to allergenic products of the fungi then, the nonlinear clusters of vesicles disseminated by the blood stream from on the hands and wrists, particularly a focus of infection (). in children, are not due to the burrow- A common form is the blistering erup- ing action of the mite. One would not tion on the sides of the fingers and expect that anyway from a morpho- on the palms from an active blistering logic viewpoint because these blisters interdigital tinea pedis. Briefly, Sulz- berger and colleagues6 gave the fol- lowing criteria for the diagnosis of dermatophytid: 1. A site of primary infection due to a pathogenic fungus (proved by labora- tory methods). 2. Evidence of allergic sensitivity from a positive trichophytin test. /1\I \ (1 3. A secondary eruption with clin- 2OOmicrons'-. ical characteristics compatible with FIG. 9-Mite of Sarcoptes scabiei. Repro- duced from "Scabies"12 by permission of those of dermatophytid at a site re- FIG. 7-Tinen corporis with peripheral E.W. Classey Ltd., Farlngdon, Oxon, moved from that of the primary lesion. blistering border. England. 158 CMA JOURNAL/JANUARY 22, 1977/VOL. 116 are not related to linear or sinuous from a patient with severe scabies. tracts with a pinhead-sized vesicle at Heilesen,13 however, found only 3 of Atromid.S* one end. In patients with scabies, ec- 38 patients with scabies to have a posi- zema occurs at sites where there are tive reaction to intracutaneous testing (clofibrate) neither burrows nor mites. with ground-up, formalin-treated ex- There are three possible explana- tract of mites. tions: I know of no studies that have to lower blood 1. Trauma itself, as from scratching, determined the nature of the antigenic may cause eczematous changes. This material in the mite. lipids safely and may explain some of the lesions but not all. Heilesen" reported papulo- Conunents effectively vesicles in paralyzed patients in areas they were unable to scratch. In experi- The slin as an organ has a limited mental scabies, lesions without mites number of reaction patterns, so one developed in areas away from the ino- should not be surprised that many dif- Indications ATROMID-S is indi- culation sites, and the number of le- ferent stimuli may cause eczema. Ur- cated where reduction of blood sions was always much higher than ticaria is another reaction pattern in lipids is desirable; e.g., patients could be accounted for by even the the skin that can result from many with hypercholesterolemia and! most rapid breeding of the mite.13 diverse external and internal stimuli. or hypertriglyceridemia. Con- 2. Many of the agents used to treat One morphologic feature of all "mi- tralndicatlons While teratogenic scabies contain elemental sulfur, which crobial" eczemas (except scabies mite studies have not demonstrated any effect attributable to ATRO- causes eczema in some patients. Also, eczema) is the tendency for the vesicles MID-S, its use in nonpregnant over-the-counter preparations used be- to be peripheral and to lift the upper women of childbearing age fore medical advice is sought may layers of the epidermis. Thus the peri- should only be undertaken in cause eczema. However, many un- pheral undermining so common in patients using strict birth control treated patients with scabies have ec- yeast, fungal and bacterial eczemas is measures. If these patients then zema. a useful diagnostic feature. plan to become pregnant, the 3. The most likely explanation is Many of the observations I have drug should be withdrawn sev- that scabetic eczema is mentioned were made years ago. It eral months before conception. a sensitivity The drug should not be given to reaction to the Sarcoptes mite. Mellan- would be profitable to investigate and lactating women. ATROMID-S is by12 has shown that an appreciable identify the possible antigenic materials not recommended in children amount of itching does not develop in by newer techniques such as immuno- since, to date, an insufficient inoculated volunteers until about 1 electrophoresis, ultracentrifugation, the number of cases have been month or longer after inoculation. Ouchterlony immune diffusion-in-gel treated. ATROMID-S is not rec- Excoriated follicular papules and ec- technique, and gas chromatography- ommended for patients with zema in areas where burrows or organ- mass spectrometry. impaired renal or hepatic func- isms cannot be demonstrated are evid- tion. Warning Caution should be The photographs and photomicrographs exercised when anticoagulants ence of this itching. Careful history were prepared by the audiovisual depart- are given in conjunction with taking, in my experience, confirms the ment of the Ottawa Civic Hospital. ATROMID-S. The dosage of the likelihood of a period after exposure anticoagulant should be reduced before severe itching developed and by one-third to one-half (depend- clinical lesions appeared. Another find- References ing on the individual case) to ing favouring a sensitivity state is 1. STORCK H: The role of bacteria in eczema, an in The Eczemas, LOEWENTHAL UA (ed), Edin- maintain the prothrombin time at increased proportion of eosinophils in burgh and London, Livingstone, 1954, pp the desired level to prevent 112-26 the blood; this has been reported in 2. LOEWENTHAL UA: Disseminated and endo- bleeding complications. Fre- 20% of patients with scabies.13'14 The genous eczemas, in The Eczemas, op cit, pp quent prothrombin determina- 142-62 fact that there is no itching time-lag in 3. EPSTEIN S: Progress in allergy; antigen- tions are advisable until it has antibody reaction in ; hypo- been definitely determined that second attacks of scabies in inoculated thesis and review. Ann Allergy 10: 633, 1952 volunteers is further evidence of a 4. MAIBACH HI, KLIGMAN AM: The bioiogy of the levels have been stabilized. experimental human cutaneous moniliasis For PRECAUTIONS and AD- sensitivity state. A final and perhaps (Candida albicans). Arch Dermatol 85: 233, 1962 VERSE REACTIONS, see scien- clinching clue is that the eczema dis- 5. HABER H: Histopathologv of eczema, in The tific brochure. Dosage and appears with treatment of scabies, even Eczemas, op cit, pp 86-98 6. SULZBERGER MB, WOLF J. WrrrEN VH. Ct ai: AdmInistratIon For adults only: though the scabetic therapy has no Dermatology; Diagnosis and Treatment, 2nd One capsule (500 mg) four times antieczematous action. ed, Chicago, Year Bk Med, 1961, p 329 daily. Availability No. 3243 - 7. SULZBERGER MB, LEWIS GM: Trichophytin Prakken and van Vloten15 carried out hypersensitiveness demonstrated by contact Each capsule contains 500 mg tests. Arch Dermatol Syphiligr 22: 410, 1930 clofibrate intracutaneous tests with extracts pre- 8. SuLzsEaoEa MB (ed): Dermatologic Allergy, N.F. in bottles of 100 Springfield, IL, CC Thomas, 1940, p 260 and 360. Further information, ref- pared from the crusts of patients with 9. JONES EH, REINHARDT JH, RINALDI MG: A erences, and scientific brochure severe generalized (or Norwegian) clinical, mycological and immunologic survey for . Arch Dermatol 108: 61, available on request. scabies, a condition in which there are 1973 10. CRUICKSHANK CND, TROTrER MD, Wooo SR: innumerable mites. The tests were done Studies on trichophytin sensitivity. / Invest in persons with typical scabies, persons Dermatol 35: 219, 1960 ii. DE Oaao GA, JOHNSON HH, BINKLEY GW: who had been treated successfully for An eczematous reaction associated with mol- luscum contagiosum. Arch Dermatol 74: 344, scabies and persons who had never had 1956 scabies. In the first group 12 of 14 12. MELLANBY K (ed): Scabies, 2nd ed, Faring- don, England, Classey, 1972 reacted positively, in the second group 13. HEILESEN B: Studies on Acarus scablel and AYERST LABORATORIES, 4 of 16 reacted positively and in the scabies. Acta Derm Venereol (Stockh) 26 division (suppi 14): 1, 1946 of third group all 18 failed to react. Pas- 14. ORMsBY OS, MONTGOMERY H (eds): Diseases Ayerst, McKenna & Harrison Limited, ol the skin 8th ed Philadelphia, Lea & Montreal, Canada sive antibody transfer (Prausnitz-Kiist- Febiger, 1954, p 128. 15. PRARKEN JR, VAN VLOTEN TI: Allergy in Made in Canada by arrangement with ner reaction) was carried out success- scabies; positive intracutaneous tests with IMPERIAL CHEMICAL INDUSTRIES LTD. fully in the third group after the pa- antigen from Scables norvegica; passive trans- fer of antibodies (Prausnitz-Kilstner). Derma- Regd. tients had been sensitized with serum tologlca 99: 124, 1949 CMA JOURNAL/JANUARY 22, 1977/VOL. 116 161